Venous Stasis Management and Ulcer HealingEvidence base and expert opinion put into practice

• Christine Herb, MS, FNP-C, CWON• Syracuse VA Medical Center• June 13, 2014

Venous vs. Arterial vs. Neuropathic

1st it is critical to correctly determine the etiology!

Lymphedema w/ Venous Stasis

Diseases Process

Bicuspid valve damage due to DVT or heredity results in venous HTN and regurgitation.White cell trapping theory: venous HTN & increased cap pressure trap leukocytes in cap & become activated, thus damaging cap beds. Increased permeability leads to fibrin cuff formation & hypoxemia, which leads to inflammation & tissue loss.

Venous stasis / insufficiency disease

We should all be more like giraffes!

Location

VS ulcer CharacteristicsIrregularly shapedGranular baseEdema & lymphedemaHemosiderin stainingVaricositiesExudateStasis DermatitisCellulitis Sharp or aching painItchingsc fibrosis

Scope of the problem

• VIU 1-3% population (Kerstein 2003)

• Peak at 60-80 yo (Pauqette & Falanga, 2002)

• 6-7 million Americans have LEVD & 1 million of those develop ulcerations

(WOCN Society 2005)

$ Costs of Venous Ulcers $• Costs:

• Lifetime costs of LEVD care est at $40,000/individual• Total cost of care of LEVD in US est at $1 billion/year (Simka & Majewski 2003)

• Ulcer Recurrence:• 57-97%, which reflects the chronicity of the problem & also failure

to effectively address the underlying etiology(Paquette & Falanga 2002)

• Repeat hospitalizations, repeat abx • Lost productivity (work, hobbies, family care, volunteering)• Loss of independence (application of compression garments)

• Pain, itching, anxiety, social isolation & reduced ability to carry out usual activities reported to be areas of greatest concern by individuals w/ venous disease (deAraujo et al, 2003)

WHAT TO DO?

Let’s start with the evidence…

AHRQ: Treatment approaches for chronic venous ulcers reviewed (Johns Hopkins University Evidence-based Practice Center :Dec 2013)

There is a general lack of conclusive evidence on the benefits and harms of advanced wound dressings, systemic antibiotics, and surgical interventions in the treatment of venous leg ulcers lasting six or more weeks in patients with preexisting venous disease

Some evidence supports:Antimicrobial dressings (mod str evidence)

Collagen dressings (low str evidence)

Bilayered human skin equivalents (mod str evidence)

Surgical procedures do not improve healing or recurrence (high str of evidence) SEPS: subfascial endoscopic perforator vein surgery

Evidence Based Treatment Compression for venous ulcers

(Cochrane review) 2009 by O’Meara, Cullum & Nelson.

• 39 RCTs reporting 47 comparisons• Author’s conclusions:

• Compression increases ulcer healing rates compared to no compression.

• Multi-component systems are more effective than single-component systems

Evidence Based Treatment Inflammatory cytokine levels in chronic

venous insuf ulcer tissue before and after compression (2009) J of Vasc Surgery. Beidler et al.

• 30 limbs untreated CVI ulcers received high compression therapy for 4 weeks.

• Biopsy of healthy & ulcerated tissue before & after therapy & using a multiplexed protein assay to measure multiple cytokines

• CONCLUSIONS: CVI ulcer healing is asso with pro-inflammatory environment prior to treatment. Treatment with compression therapy results in healing that is coupled w/ reduced pro-inflammatory cytokine levels & higher levels of the anti-inflam cytokine Il-Ra.

Evidence Based Treatment Skin grafting for venous leg ulcers

(Cochrane review) 2007 by Jones & Nelson.• 15 trials generally of poor methodology.• Author’s conclusions:

• Bilayer artificial skin, used in conjunction with compression bandaging, increases the chance of healing a venous ulcer compared with compression and a simple dressing.

• Further research is needed to assess whether other forms of skin grafts increase ulcer healing.

Evidence Based Prevention Compression for preventing recurrence of

venous ulcers (Cochran review) 2000 by Nelson, Bell-Syer & Cullum.• Author’s conclusions:

• No trials compared compression with vs no compression for prevention of ulcer recurrence.

• Not wearing compression (non-compliance in trial) was associated with recurrence in both studies indentified in this review.

• Recurrence rates may be lower in high compression hosiery than medium compression hosiery and therefore patients should be offered the strongest compression with which they can comply.

• People are more likely to wear hosiery with moderate rather than high compression.

“the integration of

•best research evidence with •clinical expertise and

•patient values”Sackett, et al. (2000)

“...in the context of available resources”

DiCenso, et al. (1998)

Evidence Based Practice

Safe to Compress?Ankle/Brachial Index• (> 1 calcified vessels)• ABI of 0.8-1.0 safe• ABI of 0.5-0.7 modified

compression may be safe

Clinical presentation of adequate perfusion:

Palp DP, PT pulses Strong doppler

signals Warm Pink color Hair on feet or toes

Compression wraps for healing

Dyna-Flex vs 3M coban

What are the essentials of effective ulcer tx?

• Effective COMPRESSION is essential !!!!• Debridement of slough and fibrin• Removing scales & moisturizing• Reduce the bioburden: antimicrobial topicals

• Medical grade HONEY• Cadexomer iodine paste• Mupirocin, bacitracin oint• Dakins sol• Bioelectric dressings

• Manage the drainage• Start simple and change one thing at a time• Progress to the advanced products if failure

• Collagen, bilayered skin substitutes, skin grafts

Fibrin can fool ya

Compression stockings

are NOT all created equal!

Compression Stockings• Anti-embolism: 16-18mmHg, TED hose are not

appropriate to tx venous stasis.• Light compression: 10-20mmHg• Class I: light support, 20-30mmHg at the ankle, usually

not adequate to prevent venous ulcer recurrence.

Class II: medium support, 30-40mmHg, level of compression needed to prevent recurrence & manage lymphedema.

Class III: strong support, 40-50mmHg, indicated for venous ulcer recurrence & manage lymphedema.

Heal the ulcers…then get them into stockings!

Important points about compression stockings:

• Change daily into clean pair• Do not pinch & pull fabric. Must use tacky rubber gloves to

stroke fabric in place.• Evenly distribute fabric.• Remove all wrinkles. Bunching fabric causes wounds!• Wash w/o bleach or fabric softener. Air dry.• Replace every 6 months!

COMPRESSION STOCKING REMINDERS

REMEMBER TO…………

Apply first thing in the morning and remove at night before bed Remove wrinkles in stocking after applying them to prevent pressure wounds Do not pull stockings up leg but to stroke them up using your rubber gloves to

avoid overstretching of your stockings Rotate all 6 pairs of your stockings to prevent stockings from wearing out and

overstretching Wear stockings only ONE day at a time then change to a clean pair Moisturize your legs at night after removing stockings before bedtime Wash stockings in laundry detergent by hand or washing machine and air dry or

on low setting in the dryer (no fabric softener or bleach)

If you have problems with applying them after training call the Wound Dept at 425-4400 ext 52827. We will help you work out the kinks!

REMEMBER to call Prosthetics Dept (425-4400 ext 54659) to reorder 6 new pairs of stockings EVERY 6 MONTHS

Throw away the 6 pairs you already have when the new ones arrive (no stock piling of old stockings!)

Enjoy these stockings!

You've made a great decision to wear compression everyday to control swelling and

prevent wounds & infection. Good job! Your legs will be very happy!

DS/Aug2011/RevMar2014

Contract

Venous Stasis Compression VENOUS STASIS DISEASE IS CHARACTERIZED BY: Spider and Varicose Veins on lower legs and feet Swelling in Feet and legs Infection Wounds Weeping Skin

You may have experienced some or all of these symptoms. Once these symptoms are brought under control you will be required to wear compression garments. These garments will; reduce swelling and prevent wounds, infection, and weeping skin from returning. This is a chronic condition and there is no "cure", but it can be managed with compression garments that will effectively prevent skin problems from returning if worn every day.

I UNDERSTAND THAT:

Compression therapy is lifelong therapy. Garments must be worn everyday (on first thing in the morning, off at night) to be effective in

preventing problems from returning. Failure to wear these garments every single day will likely result in swelling, infection, ulcers, and

possible need for hospitalization if symptoms are severe. I must contact the Prosthetics Dept (x-54659) to replace my compression garments

every _________________________.

Signing this contract I confirm understanding of venous disease and my responsibility in managing this lifelong condition.

I am committed to wearing my compression stockings everyday for the rest of my life.

Sign: _________________________________(print name/last 4:____________________________) Date: ___________

Wound Clinic: Christine Herb, FNP-C, CWON (x-54425), Diane Simcox, RN, BSN (x-52827) DS/ 3-2011

Compression Stocking Application

NOT!

Device transformed compliance

Other compression stockings

CircAid Classic-flex

CircAid Juxta-fit

Compliance is crucial• 2003 W.H.O. reported: 50% people don’t comply w/ chronic disease

management.

• “Few providers take the time to address the obstacles to non-compliance…

• Often there is a will, but the way is not shown”.Christine Herb

Keys to compliance:• Patient buy-in• ID the obstacles:

• Huge belly• Back or hip pain• Arthritis in hands

• Determine which form of compression is most do-able.• Compression is NOT for every patient; consider advanced age,

further complicating life vs benefits.• Call in all forces (spouse, friend/neighbor, adult child) to assist.• One-to-one training, demonstration & return demonstration,

encouragement, getting the kinks out & not quitting until they are successful.

• Homecare for more training in home environment & assess compliance.

Your role as PCP:• Identify venous stasis and refer to the specialists for

healing ulcers and fitting of compression garments, training, etc. Don’t wait for an ulcer or cellulitis.

• On each f/u clinic appt: PCP should assess compliance with compression garments and reinforce vital importance of wearing compression garments EVERY day for lifetime. Replace stockings every 6 months.

ManagingChronic Venous Insufficiency

• Requires compression!

to start with…

• and for a lifetime!

Thank you!

References:• Treatment approaches for chronic venous ulcers

reviewed: http://www.ahrq.gov/news/newsletters/research-activities/14feb/0214ra30.html

• Cochrane Reviews: venous ulcershttp://www.thecochranelibrary.com/details/browseReviews/576613/Ulcers-venous.html

• Resources:• http://ezyasabc.com/• WOCN.org